On behalf of myself or my minor child or other individual named below, I acknowledge and consent to the statements made in this form. I am requesting that behavioral health services be provided to me (or my minor child or other individual named below) by OhioGuidestone and its subsidiary organizations (collectively, "Agency"). I voluntarily consent to all behavioral health services, including substance use disorder services, and behavioral health-related services that providers at the Agency consider necessary. These services may include care coordination, diagnostic, therapeutic, pharmacological and laboratory services.
I understand that behavioral health services can have both benefits and risks. The risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, as behavioral health services may require discussing challenging or unpleasant life events. For children and adolescents this may manifest in behavioral reactions. I also understand, while no specific outcome is guaranteed, that the benefits of behavioral health services may include a reduction in feelings of anger or distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased feelings of well-being, increased skills for managing stress, and resolutions to specific problems. I am aware that I have the right to refuse or withdraw consent for behavioral health services at any time and that I am responsible for the potential consequences of such refusal or withdrawal.
If appropriate, I understand that I (or my minor child or other individual listed below) may be referred for pharmacological evaluation and intervention (the use of medication). I understand that I have the right to refuse to take specific medications, or to participate in specific treatment options. In the event I choose to reject a treatment recommendation, my provider will explain the possible consequences of this refusal and the risks of alternative treatment options, or no treatment.
I understand that the Agency may wish to provide treatment or services to me or my minor child (or other individual named below) using telehealth. Telehealth is the form of telemedicine that allows clients to access behavioral health care using audio and/or audio/video interface technologies such as videoconferencing and telephone. The Agency has explained to me how telehealth technology will be used to provide treatment and services.
I understand the expected benefits of telehealth may include improved access to services; additional convenience for the client; more efficient management of behavioral health services; and obtaining the expertise of a distant specialist. The potential risks to telehealth technology may include technological difficulties that disrupt effective and timely communication or service delivery and unauthorized access causing a breach of privacy of protected health information. I understand that my use of a public computer, a device on a shared network, use of non-encrypted communication, or auto-fill features all present risks to the security of my private information. I have discussed the technology requirements necessary for my telehealth service. I understand that there is a possibility of technology failure during a service and will follow the service disruption procedure in case of such a failure. The Agency or I can discontinue the telehealth appointment if the technology connections are not adequate for the situation.
I am aware of anticipated response times to electronic communication, alternative service deliveries, and expectations regarding electronic communication between scheduled appointments and outside of normal business hours. I understand that the Agency cannot ensure confidentiality (1) at a non-Agency site; (2) when non-Agency equipment or software is used; or (3) when Agency telehealth procedures are not followed. I understand these risks and I agree to assume these risks for any telehealth services I may receive. I consent to participate in telehealth services. I understand that I have the right to withhold or withdraw consent to the use of telehealth at any time, without affecting the right to future care or treatment.
I consent to receive email messages and text messages, including automated messages, from Agency. These messages may contain my protected health information. I am aware that text messages are not secure and there is a risk a text message could be read by a third party. By choosing to receive text message from Agency, I acknowledge and accept the inherent risks of text messages.
If I do not wish to consent to email messages or text messages, I may opt out by notifying my provider or the Agency Privacy Officer.
In the event of an emergency, I understand I should call 911 or go directly to my nearest emergency room.